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Swimming/AquaticConsent Form

CONFIDENTIAL

To be completed by the Parent/Guardian for students participating in swimming and aquatics activities. This

form will be shown to School Staff and Swimming Instructors and Emergency Services Personnelresponsible for this students safety at swimming and aquatics activities.ST!"E#TS $I%% #&T 'E PE()ITTE" T& P*(TI+IP*TE $IT,&!T * +&)P%ETE" *#" SIG#E"

+SE#T -&()

Section 1: Person Details

Student #ame"ate of 'irth

#ame of School )edic *lert #o. if relevant0.

Emergency +ontact Person +ontact #o

Section : !ealt" Su##ort In$ormation

Please complete the following information so the instructors and school staff can plan for your childssafety in the water.

"oes your child have a health care need that could affect their safety in the water1If #& 2 please go to section 3 2 consent to participate in Swimming or *quatics *ctivities.

If 4ES 2 please complete this section

If you tic5 any of the bo6es below the Swimming and *quatic Instructors need a written health care planfrom your childs doctor/treating health professional. This may be a copy of the information you haveprovided already to the school.I)P&(T*#T7 failure to provide required medication will result in standard -irst *id )anagement in anemergency.

 *sthma Sei8ures9 Epilepsy

Severe allergy e.g. bee sting0 "iabetes

:oint disorder ,eart "isorder  

;ision impairment ,earing impairment

Ear disorder S5in condition

Incontinence Swallowing/cho5ing

)edication usually ta5en at school +ommunication difficulties

&ther please provide details0

,ave you attached health care details from your childs doctor/treating health professional1 4es/#oIf #&9 staff and instructors will provide standard supervision for safety and first aid see over0If 4ES9 write down what you have attached and please ensure all relevant medication is provided.

Section %: & Consent to ta'e #art in swimming or aquatics acti(itiesI give my consent for my child named above to participate in swimming or aquatic activitiesI understand that school staff will be present and provide supervision for safety.

I understand that the swimming or aquatic instructor will be in charge of the water activities.

Parent/guar)ian*Signature..Date

8/18/2019 Swimming and Aquatics Cons En

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